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If your claim or a medical condition is denied
The
insurer must accept or deny your claim within 60 days from the day you tell your employer
about the injury. If your claim is denied, the insurer will tell you about your appeal rights
in the denial letter they send to you. An “appeal” is a request by you, an insurer
or someone else for a review of a decision made about your claim. If you receive a notice
that your claim or benefits are denied or ended, the document you receive will have instructions
on how to appeal if you disagree with the decision. There are time limits for most appeals,
and you’ll lose your appeal rights if you don’t appeal within those limits. Benefits
that are the subject of the appeal are usually not paid until the review of the decision
is completed and there is no further appeal. If you want legal advice, check the yellow pages
of your phone directory under “Attorneys” or contact the Oregon State Bar, 800-452-7636,
to find a lawyer who handles workers’ compensation in your area.
The insurer will pay time-loss authorized by your doctor up until the day your claim is denied.
You won’t have to repay time-loss benefits if your claim is denied. However, if your
claim is denied within two weeks of the date you reported the claim to your employer, you
will not receive time-loss payments.
Worker
requested medical examination
If your claim has been denied by the insurer based on an insurer medical examination (IME),
and your doctor (attending physician) disagrees with the IME results, you may be eligible
to request a medical examination by a doctor chosen by the Workers’ Compensation Division.
In order to be eligible for this exam, you must appeal your denied claim in writing within
60 days of the denial. After you have requested an appeal on the denial, you may send a written
request for an exam to WCD. A copy of your request should be sent simultaneously to the insurer
or self-insured employer. The request must include:
Claim disposition agreement (CDA)
On an accepted claim, you may enter into a CDA. This is a legal agreement
where in return for an agreed-upon amount of money, you give up your right to the following:
Present and future time-loss benefits, present and future permanent partial disability awards,
monthly payments for permanent total disability, vocational assistance benefits, and aggravation
rights to reopen your claim. However, you cannot release your right to medical benefits or
eligibility for the Preferred Worker Program. All claim disposition agreements are reviewed
by the Workers’ Compensation Board, which approves or disapproves the agreement. If
you have questions about claim disposition agreements, contact the Ombudsman for Injured
Workers 1-800-927-1271.
Disputed claim
settlement (DCS)
When you disagree with the insurer about whether you have a valid workers’
compensation claim, you and the insurer may agree to a cash settlement for the claim. If
you agree, your claim will be denied, and you give up all rights to future benefits for the
denied medical conditions of the claim. Medical providers may bill you for unpaid services,
so find out what your obligations will be before you agree to a settlement.
When your claim
is closed
You will receive a Notice of Closure from the insurer. This is a
legal document that closes your claim. It lists the periods for which time-loss was authorized
and tells you how much permanent disability has been determined. This document also tells
you what to do if you want to appeal the closure.
What
does “closure” mean?
Disabling claims are “open” while you are recovering from your
injury and must be “closed” when you are medically stationary. Your claim will also be closed if your work injury is no longer the major
cause of your disability or if you fail to keep medical appointments. The following important
documents will be mailed to you when your claim is closed:
A Notice of Closure
from the insurer. This is the legal document that closes your claim. It lists the
periods for which time-loss was authorized and tells you how much permanent disability
you may have. This document also tells you what to do if you want to appeal the closure.
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An Updated Notice
of Acceptance at closure, which lists all of the medical conditions the insurer
has accepted. If the updated notice is incomplete or incorrect, notify the insurer
in writing.
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Claim
closure appeal rights:
If you disagree with the Notice of Closure, you have the right to appeal the closure
of your claim by asking the Workers' Compensation Division for a “Reconsideration”
within 60 days from the mailing date printed in box 1 on the front of the form. If you do
not appeal within 60 days, you will lose all rights to appeal your claim closure. Your appeal
rights and the address to which to send your appeal are printed on the back of the Notice
of Closure.
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Ways
to request reconsideration of your claim closure:
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Fill out and mail a Request
for Reconsideration form
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Send form by electronic transmission (by facsimile or FAX)
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Hand deliver form to a Workers' Compensation Division office
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Request by phone or in-person — Ask to speak to an appellate reviewer
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Reconsideration
process
When the Appellate Review Unit of the Workers’ Compensation Division
receives your request for reconsideration, an acknowledgment letter is mailed to the insurer,
the injured worker, and attorneys, if any are involved. This letter tells you that the reconsideration
process has begun.
Reconsideration is an informal review process, not a hearing. You may talk to your reviewer
and you may submit a written statement explaining your condition and your disagreement with
the claim closure. You may also submit statements from others to support your position. This
will be your last opportunity to provide new information about your claim.
An Order on Reconsideration may either be issued by the Workers’ Compensation Division
on the 18th working day from the date of the initial request by you, or it may be postponed
for 18 working days (plus an additional 60 days) if more information is needed or a medical
arbiter exam is requested. If the process is postponed, you will receive a postponement letter,
which will tell you we are postponing our decision because we are requesting additional information
or scheduling a medical arbiter exam.
Brochures and forms
Medical
arbiter examinations
The medical arbiter exam is scheduled by WCD's Appellate Review Unit staff
to settle disputes over your impairment findings and is based on your accepted condition(s)
at the time of your claim's closure. Your reviewer will ask the medical arbiter physician
questions about your accepted condition(s). Because the focus of the exam is determining
your impairment, the medical arbiter is not authorized to offer you any medical treatment.
For more detailed information about the medical arbiter process, refer to What
is a medical arbiter examination? | Espanol
A medical arbiter is a physician appointed by the Workers’ Compensation Division
to perform an impartial examination and review your records. The physician is randomly chosen
from our list of medical arbiters within the medical specialty that reflects your claim.
The medical arbiter will be a physician you have not seen as a patient.
The medical arbiter must be a medical doctor as defined by Oregon statute and must be in
good standing with the Oregon Medical Board.
All physicians must undergo medical arbiter training prior to their first arbiter exam. Medical
arbiter reports are monitored by WCD to ensure quality and impartiality.
If a medical arbiter exam is scheduled, you will receive an appointment letter with a date,
time and location. If you do not keep your exam appointment and do not have a good reason
for missing it, your disability benefits may be suspended. You must contact the Appellate
Unit staff within 24 hours after the missed appointment.
When
there is a medical treatment dispute
Treatment disputes may be initiated by any party using Form
2842. The insurer can request administrative review if they think treatment is excessive,
inappropriate, unnecessary, or in violation of a medical services rules. The physician can
request administrative review if the insurer does not approve a palliative care, elective
surgery, or experimental treatment request.
For additional information on requests for administrative review of medical issues, refer
to Bulletin
293.
Medically Stationary
Medically stationary means that your doctor has determined that your condition or injury is not expected to get better with further treatment or the passage of time. |
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